Pneumonia

Question 1

Define Pneumonia

Answer 1

An acute lower respiratory tract infection illness associated with fever, symptoms, signs in the chest and abnormalities on the CXR

Question 2

What are the symptoms of pneumonia?

Answer 2

Systemic upset - Fever, rigors, vomiting
Cough - Short, dry, painful, progressing to productive w/ mucopurulent sputum
Dyspnoea
Pleuritic pain
Ederly pts acutely confused

Question 3

What are the signs of pneumonia?

Answer 3

Tachypnoea
Decreased chest expansion, dull to percussion (affected area)
Coarse crackles, pleural rub w/ bronchial breathing (affected side)
Increased vocal resonance
Upper abdo tenderness (lower lobe pneumonia)

Question 4

Describe the CURB65 score

Answer 4

Measure of pneumonic severity
Confusion
Urea >7mmol/L
Resp rate >30
BP <90s OR <60d
>65

Question 5

What are the three CURB65 classifications of Pneumonia?

Answer 5

0-1 = Mild, home if possible, PO a/b
2 = Moderate, hospital admission, IV a/b
3 = Severe, poss ITU, IV a/b

Question 6

What are the common pathogens causing CAP?

Answer 6

Conventional (60-80%) - Strep. pneumoniae, H. influenzae
Atypical (10-20%) - Mycoplasma, chylamydia, legionella
Virual (10-20%) - Influenza/parainfluenza

Question 7

What are the common pathogens causing HAP?

Answer 7

G- enterobacteria
S. aureus
Pseudomonas
Klebsiella
Bacteroides
Clostridia

Question 8

What factors predispose patients to Pneumonia?

Answer 8

Smoking
Asthma
COPD
Age
Immunodeficiency
Alcohol

Question 9

Define lobar pneumonia

Answer 9

Pneumonia affecting a large and continuous area of the lobe of a lung due to bacteria gaining entry to distal air spaces
Pts normally adults, severely ill

Question 10

What are the causative organisms of lobar pneumonia?

Answer 10

Strep. pneumoniae
H. influenzae
Moraxella catarrhalis
M. tuberculosis

Question 11

What are the four histological stages of lobar pneumonia?

Answer 11

Congestion (<24hrs)
Red hepatization/consolidation
Grey hepatization
Resolution

Question 12

Define Bronchopneumonia

Answer 12

Pneumonia where the primary infection centres around the bronchi, spreading to adjacent alveoli

Question 13

What are the causative organisms of Bronchopneumonia?

Answer 13

Staph. aureus
Strep. pneumoniae
H. influenzae
Proteus
E. coli

Question 14

What is the pathology behind Bronchopneumonia?

Answer 14

Initial consolidation patchy, can become confluent
Most common in infancy/old age
Most commonly affects lower lobes

Question 15

How should Pneumonia be investigated?

Answer 15

CXR
Bloods -  FBCs, U&Es, CRP, LFTs
Blood cultures
Urine antigen (Legionella/pneumococcal)
MC&C on sputum/aspirate
Serum mycoplasma IgM
Viral throat swab

Question 16

What signs of Pneumonia are present on a CXR?

Answer 16

Lobar/multilobar infiltrates
Cavitation
Pleural effusion

Question 17

What are the complications of Pneumonia?

Answer 17

Parapneumonic effusion/empyema
Post-infective bronchiectasis
Lung abscess (clubbing)
Sepsis

Question 18

What antibiotic therapy is given in Pneumonia?

Answer 18

Mild - amox + doxy
Mod - amox + clarith + doxy
Severe - co-amox + clarith

Question 19

What physiotherapy can be given in Pneumonia?

Answer 19

Admission avoidance
Management of resp failure
Management of airway secretions
Reduce breathing work
Manage co-morbidities
Recovery from illness

Question 20

What is HAP?

Answer 20

Hospital acquired pneumonia
Pneumonia developing <48hrs after admission w/ no signs of incubation on admission OR developing w/i 10 days of discharge

Question 21

Describe a S. pneumoniae infection

Answer 21

Most common cause of CAP (if no COPD)
Vaccine, given to immunocompromised
Causes lobar pneumonia & ‘rust-coloured’ sputum

Question 22

Describe a H. influenzae infection

Answer 22

Capsulated strain decreasing due to HiB vaccine

Non-capsulated common in COPD

Question 23

Describe a M. pnuemoniae infection

Answer 23

Suspect in young pts (>40%)
Long hx of illness w/ extra-pulmonary features - rash, hepatitis, D&V, pericarditis, meningoencephalitis
Patchy consolidation on CXR
Treat w/ Erythromycin for 2/52

Question 24

Describe a L. pneumoniae infection

Answer 24

Sporadic & outbreaks
Resides in air con units, common in smokers returning from holiday
Severe disease w/ hypernatremia & CN palsies
Proteinuria & haematuria
Treat w/ Erythromycin for 2/52

Question 25

Describe a C. pneumoniae infection

Answer 25

URTIs in infancy, CAP in elderly

Question 26

Describe a S. aureus infection

Answer 26

Can cause CAP during an influenza outbreak

Treat w/ standard regimens + Flucloxacillin

Question 27

What is the treatment for a CAP w/ a CURB65 score of 0/1?

Answer 27

Non-severe (<3% mortality)
Oral amoxicillin as outpt
Oral doxycycline if penicillin allergic

Question 28

What is the treatment for a CAP w/ a CURB65 score of 2?

Answer 28

Moderately severe (9% mortality)
Oral amoxicillin + clarithromycin, admit pt
Oral doxycycline if penicillin allergic

Question 29

What is the treatment for a CAP w/ a CURB65 score of >2?

Answer 29

IV clarithromycin + co-amoxiclav, admit to HDU
Levofloxacin + Vancomycin if penicillin allergic/MRSA
Treat >10/7

Question 30

What a/b should be added to CAP treatment regimens if aspiration is suspected?

Answer 30

Metronidazole

Question 31

What is the management for HAP?

Answer 31

Assess MRSA risk factors (colonisation, prev infection, central line etc.)
Mild - Oral doxycycline
Severe - Oral co-trimoxazole

Question 32

When should pts have a follow up CXR?

Answer 32

6 weeks

If no resolution consider endobronchial obstruction as cause (tumour)